“That’s a long vacation,” the patient remarked, and the intern, believing that sharing the news of his wedding would be too personal, decided instead to focus on the patient’s comment. What would it be like for her to miss three weeks of sessions? What did her feelings about his absence remind her of? Both of which might be fruitful avenues to explore, but so would the patient’s indirect question: Since it’s neither summer nor a holiday season, why are you really taking three weeks off? And sure enough, when the intern returned to work, the patient noticed his wedding ring and felt betrayed: “Why didn’t you just tell me the truth?”
In retrospect, the intern wished he had. So what if a patient learned that he was getting married? Therapists get married and patients have reactions to that. Those can be worked through. Loss of trust is harder to repair.
Freud argued that “the physician should be impenetrable to the patient, and like a mirror, reflect nothing but what is shown to him.” Nowadays, though, most therapists use some form of what’s known as self-disclosure in their work, whether it’s sharing some of their own reactions that come up during the session or acknowledging that they watch the TV show that a patient keeps referring to. (Better to admit that you watch The Bachelor than to feign ignorance and slip up by naming a cast member the patient hasn’t mentioned yet.)
Inevitably, though, the question of what to share gets tricky. One therapist I know told a patient whose child was diagnosed with Tourette’s syndrome that she, too, had a son with Tourette’s—and it deepened their relationship. Another colleague treated a man whose father had committed suicide but never revealed to the patient that his own father had also committed suicide. In each situation, there’s a calculation to make, a subjective litmus test we use to assess the value of the disclosure: Is this information helpful for the patient to have?
When done well, self-disclosure can bridge some distance with patients who feel isolated in their experiences, and it can encourage more openness. But if it’s perceived as inappropriate or self-indulgent, the patient will feel uncomfortable and start to shut down—or simply flee.
“Yes,” I tell Julie. “It’s a pajama top. I guess I put it on by mistake.”
I wait, wondering what she’ll say. If she asks why, I’ll tell the truth (although not the specifics): I wasn’t paying attention this morning.
“Oh,” she says. Then her mouth twitches the way it does when she’s about to cry, but instead, she starts laughing.
“I’m sorry, I’m not laughing at you. Namast’ay in Bed . . . that’s exactly how I feel!”
She tells me about a woman in her Mindful Cancer program who’s convinced that if Julie doesn’t take yoga seriously—along with the famous pink ribbons and the optimism—her cancer will kill her. Never mind that Julie’s oncologist has already informed her that her cancer will kill her. This woman still insists it can be cured with yoga.
Julie despises her.
“Imagine if I walked into yoga wearing that top and—”
Now she’s laughing uncontrollably, reining it in and then bursting out with another round. I haven’t seen Julie laugh once since she learned she was dying. This must be what she was like in what she calls “B.C.” or “Before Cancer,” when she was happy and healthy and falling in love with her soon-to-be husband. Her laughter is like a song, and it’s so contagious that I start laughing too.
We both sit there laughing, her at the sanctimonious woman, and me at my mistake—at the ways in which our minds betray us as much as our bodies do.
Julie discovered her cancer while having sex with her husband on a beach in Tahiti. She didn’t suspect it was cancer, though. Her breast felt tender, and later, in the shower, the tender spot felt funky, but often she had areas that felt funky and her gynecologist always found them to be glands that changed size at certain times of the month. Anyway, she thought, maybe she was pregnant. She and her new husband, Matt, had been together for three years and both had talked about wanting to start a family as soon as they got married. In the weeks before the wedding, they hadn’t been vigilant about birth control.
It was a good time to have a baby too. Julie had just gotten tenure at her university, and after years of hard work, she could finally take a breath. Now there would be more time for her passions: running marathons and climbing mountains and baking silly cakes for her nephew. There would also be time for marriage and parenthood.
When Julie got back from her honeymoon, she peed on a stick and showed it to Matt, who picked her up and danced around the room with her. They decided that the song that happened to be on the radio—“Walking on Sunshine”—would be their baby’s theme song. Excited, they went to the obstetrician for their first prenatal appointment, and when her doctor felt the “gland” that Julie had noticed on her honeymoon, his smile faded slightly.
“It’s probably nothing,” he said, “but let’s get it checked out.”
It wasn’t nothing. Young, newly married, and pregnant, with no family history of breast cancer, Julie had been struck by the randomness of the universe. Then, while grappling with how to handle the cancer treatment and the pregnancy, she had a miscarriage.
This was when Julie landed in my office.
It was an odd referral, given that I wasn’t a therapist who specialized in treating people with cancer. But my lack of expertise was exactly why Julie wanted to see me. She had told her physician that she didn’t want a therapist from “the cancer team.” She wanted to feel normal, to be part of the living. And since her doctors seemed confident that she’d be fine after surgery and chemo, she wanted to focus on both getting through the treatment and being newly married. (What should she say in her wedding-gift thank-you notes? Thanks so much for the lovely bowl . . . I keep it by my bed to vomit in?)
The treatment was brutal but Julie got better. The day after her doctors declared her “tumor-free,” she and Matt went on a hot-air balloon ride with their closest friends and family. It was the first week of summer, and as they joined arms and watched the sunset from a thousand feet above the earth, Julie no longer felt cheated, as she had during the treatment, but lucky. Yes, she’d gone through hell. But it was behind her, and her future lay ahead. In six months, she would get a final scan, a sign-off, to clear her for pregnancy. That night, she dreamed that she was in her sixties and holding her first grandchild.
Julie was in good spirits. Our work was done.
I didn’t see Julie between the hot-air balloon ride and the scan. But I did start getting calls from other cancer patients who’d been referred by Julie’s oncologist. There’s nothing like illness to take away a sense of control, even if we often have less of it than we imagine. What people don’t like to think about is that you can do everything right—in life or in a treatment protocol—and still get the short end of the stick. And when that happens, the only control you have is how you deal with that stick—your way, not the way others say you should. I’d let Julie do it her way—I was so inexperienced that I didn’t have a strong sense of what a “way” should look like—and it seemed to help.
“Whatever you did with her,” Julie’s oncologist said, “she seemed pleased with the outcome.”
I knew that I hadn’t done anything brilliant with Julie. Mostly, I worked hard not to flinch from her rawness. But that rawness went only so far because we weren’t even thinking about death then. Instead, we discussed wigs versus scarves, sex and postsurgery body image. And I helped her think through how to manage her marriage, parents, and work, much the way I might with any patient.
Then one day I checked my messages and heard Julie’s voice. She wanted to see me right away.
She came in the next morning, ashen. The scan that was supposed to show nothing had instead found a rare form of cancer, different from the original. In all likelihood, this cancer was going to kill her. It might take a year or five or, if things went very well, ten. Of course, they would explore experimental treatments, but they were just that—experimental.
“
Will you stay with me until I die?” Julie asked, and though my instinct was to do what people tend to do whenever somebody brings up death, which is to deny death completely (Oh, hey, let’s not go there yet. Those experimental treatments might work), I had to remember that I was there to help Julie, not comfort myself.
Still, at the moment she asked, I was stunned, still absorbing the news. I wasn’t sure I was the best person for this. What if I said or did the wrong thing? Would I offend her if my feelings—discomfort, fear, sadness—came across in my facial expressions or body language? She was going to get only one chance at doing this the way she wanted. What if I let her down?
She must have seen my hesitation.
“Please,” she said. “I know it’s not a picnic, but I can’t go to those cancer people. It’s like a cult. They call everyone ‘brave,’ but what choice do we have, and besides, I’m terrified and still cringe at the sight of the needles like I did as a kid getting my shots. I’m not brave and I’m not a warrior fighting a battle. I’m just an ordinary college professor.” She leaned forward on the couch. “They have affirmations on their walls. So, please?”
Looking at Julie, I couldn’t say no. More important, now I didn’t want to.
And right then, the nature of our work together changed: I was going to help her come to terms with her death.
This time, my inexperience might matter.
6
Finding Wendell
“Maybe you should talk to someone,” Jen suggests two weeks after the breakup. She has just called to check on me at work. “You need to find a place where you’re not being a therapist,” she adds. “You need to go where you can completely fall apart.”
I look at myself in the mirror that hangs by the door in my office, the one I use to make sure I don’t have lipstick on my teeth when I’m about to retrieve a patient from the waiting room after a quick snack between sessions. I appear normal, but I feel dizzy and disoriented. I’m fine with patients—seeing patients is a relief, a full fifty minutes of respite from my own life—but outside of sessions, I’m losing it. In fact, as each day goes by, I seem worse, not better.
I can’t sleep. I can’t concentrate. Since the breakup, I’ve left my credit card at Target, driven out of the gas station with my tank’s cap hanging off, and fallen off a step in my garage, badly bruising my knee. My chest hurts as if my heart has been crushed, though I know it hasn’t been, because if anything, my heart is working harder, beating rapidly 24/7—a sign of anxiety. I obsess about Boyfriend’s state of mind, which I imagine is calm and unconflicted, while I lie on my bedroom floor at night and miss him. Then I obsess about whether I really miss him—did I even know him? Do I miss him, or do I miss the idea of him?
So when Jen says I should see a therapist, I know she’s right. I need someone to help me through this crisis.
But who?
Finding a therapist is a tricky thing. It’s not like looking for, say, a good internist or dentist because pretty much everyone needs an internist or dentist. A therapist, though? Consider:
If you ask somebody for a therapist recommendation and that person isn’t seeing a therapist, he or she might be offended that you’d made that assumption. Similarly, if you ask somebody for a therapist recommendation and that person is seeing a therapist, he or she might be upset that it was so apparent to you. Of all the people she knows, this person might wonder, why did she think to ask me?
When you inquire, you risk this person asking why you want to see a therapist. “What’s wrong?” this person might say. “Is it your marriage? Are you depressed?” Even if people don’t ask this aloud, every time they see you, they might be silently wondering, What’s wrong? Is it your marriage? Are you depressed?
If your friend does give you her therapist’s name, there might be unexpected checks and balances to what you say in the therapy room. If, for instance, your friend recounts to this therapist a not-so-flattering incident that involves you, and you give a different version of this same incident—or omit it altogether—the therapist will see you in a way you haven’t chosen to present. But you won’t know what the therapist knows about you, because the therapist can’t mention anything said in somebody else’s session.
These caveats notwithstanding, word of mouth is often an effective way to find a therapist. You can also go on PsychologyToday.com and sort through profiles in your area. But however you do it, you may need to meet with a few before you find the right one. That’s because clicking with your therapist matters in a way that it doesn’t with other clinicians (as another therapist said: “It’s not the same as choosing a good cardiologist who sees you maybe twice a year and will never know about your massive insecurity”). Study after study shows that the most important factor in the success of your treatment is your relationship with the therapist, your experience of “feeling felt.” This matters more than the therapist’s training, the kind of therapy they do, or what type of problem you have.
But I have unique constraints in finding a therapist. To avoid an ethical breach known as a dual relationship, I can’t treat or receive treatment from any person in my orbit—not a parent of a kid in my son’s class, not the sister of my coworker, not a friend’s mom, not my neighbor. The relationship in the therapy room needs to be its own, distinct and apart. These rules don’t hold for other health-care clinicians. You can play tennis or be in a book club with your surgeon, dermatologist, or chiropractor, but not with your therapist.
This narrows my prospects dramatically. I’m friendly with, refer patients to, go to conferences with, or otherwise associate with numerous therapists in town. On top of that, my friends who are therapists, like Jen, know many of the same therapists I do. Even if Jen referred me to one of her colleagues that I don’t know, there would be something awkward about her being friendly with my therapist—it’s too close. And as for my asking my colleagues? Well, there’s this: I don’t want my colleagues to know I’m seeking urgent therapy. Might they hesitate, consciously or not, to send referrals my way?
So while I’m surrounded by therapists, my predicament conjures that Coleridge line “Water, water, everywhere / Nor any drop to drink.”
But by the end of the day, I have an idea.
My colleague Caroline isn’t in my suite, or even in my building. She’s not a friend, although we’re professionally friendly. Sometimes we share cases—I’ll see a couple, and she’ll see one of the members of the couple individually, or vice versa. Any referral she’d have, I’d trust.
I dial her cell at ten to the hour, and she picks up.
“Hi, how are you?” she asks.
I say I’m great. “Absolutely great,” I repeat enthusiastically. I don’t mention the fact that I’ve barely slept or eaten and feel like I might faint. I ask how she is, then get right to the point.
“I need a referral,” I say, “for a friend.”
I quickly explain that this “friend” is looking specifically for a male therapist to keep Caroline from wondering why I’m not referring my friend to her.
Through the phone, I can almost hear the gears turning in her head. About three-fourths of clinicians who do therapy (as opposed to research, psychological testing, or medication management) are women, so it takes some thought for her to find a man. I add that the one male therapist in my office suite, who happens to be one of the most talented therapists I know, won’t work out for this friend because this friend doesn’t feel comfortable doing therapy at my office, where we share a waiting room.
“Hmm,” Caroline says. “Let me think. It’s a male patient who wants the referral?”
“Yes, he’s in his forties,” I say. “High-functioning.”
High-functioning is therapist code for “a good patient,” the kind most therapists enjoy working with, often to balance out the patients we also want to work with but who are less high-functioning. High-functioning patients are those who can form relationships, manage adult responsibilities, and have a capacity for self-reflection
. The kind who don’t call daily between sessions with emergencies. Studies show, and common sense dictates, that most therapists prefer to work with patients who are verbal, motivated, open, and responsible—these are the patients who improve more quickly. I include the high-functioning bit with Caroline because it broadens the range of therapists who might be interested in this case, and, well, I consider myself to be relatively high-functioning. (At least, I did until recently.)
“I think he’d feel more comfortable with a male therapist who’s also married with kids,” I continue.
I add this for a reason too. I know this isn’t a fair assumption, but I’m afraid that a female therapist might be predisposed to empathize with me post-breakup and that a male therapist who’s neither married nor a father won’t understand the nuances of the kid part of the situation. In short, I want to see if an objective male professional who has firsthand experience of marriage and kids—a man just like Boyfriend—will be as appalled at Boyfriend’s behavior as I am, because then I’ll know that my reaction is normal and I’m not going insane after all.
Yes, I’m seeking objectivity, but only because I’m convinced that objectivity will rule in my favor.
I hear Caroline clicking away on her keyboard. Tap, tap, tap.
“How about—no, scratch that, he thinks much too highly of himself,” she says of some unnamed therapist. She goes back to her keyboard.
Tap, tap, tap.
“There’s a colleague who used to be in my consultation group,” she begins. “But I’m not sure. He’s great. Very skilled. He always has insightful things to say. It’s just—”
Caroline hesitates.
“Just what?”
“He’s so happy all the time. It feels . . . unnatural. Like, what the hell is he so happy about? But some patients like that. Do you think your friend would do well with him?”
“Definitely not,” I say. I, too, am suspicious of chronically happy people.
Maybe You Should Talk to Someone Page 4